Designation of Health Care Surrogate

I, ACCOUNT_FIRST_NAME ACCOUNT_LAST_NAME, designate the following individual as my primary health care surrogate to make health care decisions on my behalf:

Primary Healthcare Surrogate:

DETAILS

If my primary health care surrogate is unwilling, unable, or unavailable to act, I designate as my alternate healthcare surrogate:

INFO

INSTRUCTIONS:

I authorize my health care surrogate to:

(a) make health care decisions and to provide, withhold, or withdraw consent on my behalf; or
(b) Obtaining, reviewing, and disclosing my medical records as necessary for my care.

(c) apply for public benefits to defray the cost of health care; and to authorize my admission to or transfer from a health care facility

(d) SPECIAL_INSTRUCTIONS

EFFECTIVE DATE OF SURROGATE'S AUTHORITY

My health care surrogate’s authority becomes effective only upon a determination by my primary physician that I am unable to make my own health care decisions due to incapacity or any other medical condition that impairs my decision-making ability.

ACCOUNT_SIGN_BLOCK

Witness 1:

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